Use of second-generation antipsychotics to treat off-label conditions rises significantly among Medicaid-enrolled children

Mental Health

The use of antipsychotic drugs to treat psychiatric disorders of children, adolescents, and young adults continues to increase, along with concern that prescribing is expanding beyond indications supported by evidence about their effectiveness and safety. In fact, a national study reveals that second-generation antipsychotic (SGA) treatment climbed by 62 percent among Medicaid-enrolled children between 2002 and 2007, reaching 354,000 youth (2.4 percent) in the final year of the study.

The highest rates of SGA treatment growth were among school-aged children and adolescents diagnosed with attention deficit hyperactivity disorder (ADHD), intellectual disabilities, and developmental delay and/or learning disabilities. By 2007, half of all children receiving SGAs had ADHD listed as one of their diagnoses and one in seven (14 percent) had ADHD as their only mental health diagnosis.

ADHD was not only the most prevalent diagnosis, but the diagnosis with the highest increase in rates of treatment across all ages. Neither the American Academy of Pediatrics nor the American Academy of Child and Adolescent Psychiatry recommends SGA treatment for the management of ADHD. Among school-aged children and adolescents, the diagnosis of ADHD grew from 37 to 45 per 1,000 among 6- to 11-year olds and from 24 to 32 per 1,000 among 12- to 18-year olds. Among 6- to 11-year olds, proportional use of SGA was highest among children with the diagnoses of bipolar disorder and schizophrenia (70 and 61 percent, respectively). In adolescents aged 12 to 18-years, those with a diagnosis of schizophrenia, bipolar disorder, and autism were proportionately the highest SGA users (76, 62, and 43 percent, respectively).

Several SGAs have received U.S. Food and Drug Administration approval for the treatment of schizophrenia and bipolar disorder in older children or adolescents (10 to 17 years). Two SGAs are approved for treating irritability associated with autism in children as young as 5 years of age. Other approvals for children younger than 10 years of age are few and limited to schizophrenia, bipolar disorder, and severe behavioral problems. Given their study’s findings of expanding off-label use of SGAs among children, the researchers recommend further scrutiny of their safety and efficacy in this population. Their findings were based on analysis of Medicaid Analytic Extract files for 50 States and the District of Columbia from 2002 to 2007.

The study was supported in part by AHRQ (HS18550). See "The relationship between mental health diagnosis and treatment with second-generation antipsychotics over time: A national study of U.S. Medicaid-enrolled children," by Meredith Matone, M.H.S., Russell Localio, Ph.D., Yuan-Shung Huang, M.S., and others in the October 2012 HSR: Health Services Research 47(5), pp. 1836-1860.